In the past, I might be harsher in jumping down someone’s throat if I heard too much ‘armchair doctoring’. But being on guard around these kinds of conversations is a costly time sink. Lately I’m more mild mannered and just let people think what they want about pain and injury.

But, and this is important, when someone has a stage and an audience such as the JRE does, misinformation can travel much faster and have a far more negative effect on those it touches than idle chatter on the mat between two training partners who share knee pain.

If you’ve already read my initial Facebook post, then scroll past the next section to the next part of the breakdown. If you haven’t below is the exchange that made it clear that I should interject some real medicine into the conversation:

In a facebook message:

“Hey Carlos, what are your thoughts regarding the use of a Reverse hyper machine for back/disk issues?”

My answer went like this:

”It’s no prob at all. Generally smart to strength train your posterior chain, hamstrings, glutes and back extensors. That piece of equipment is a good way to do it.”

Note, that up until this point, I’d not heard the episode in full, but when I did…

LOL. Just realized that you prob heard this from the Joe Rogan/Danaher podcast, didn’t you?
Pretty much every gym has this piece of equipment (the reverse hyper) but that doesn’t mean it’s the best piece or move to strengthen your posterior chain.
Maybe I’ll put together a short piece for our training fam explaining this further.
Could be useful for training partners struggling with back pain or disc issues.

Here was the portion of the show that my training partner was referring to:

Episode Timer: 1:11:25 (D: Danaher, R: Rogan)

D: “I’ve developed a strong need for ibuprofen all of my life”

R: “I have a machine I have to show you. It’s called a reverse hyper; ever heard of it? It’s a life changer”

D: “Yeah I’ve heard of it…” I can’t use one now because I have a hip replacement and when you go up it puts extreme shearing force on a hip replacement. I can do it with body weight but I can’t do it with a weight.”

This exchange is typical of how people with pain share information. Person 1 is talking about pain. Person 2 commiserates and offers up some solution. This is perfectly well-meaning, but the nature of pain and how we get out of pain is so far from a one-size-fits-all approach that this advice is almost meaningless. Making a blanket statement about a single piece of equipment, a single nutrition program, or single exercise and how it will “change your life” is just ridiculous. There is no cure all. There is no BEST single anything. The best movers among us use a combination of approaches in their exercise, training and nutrition programs to elicit their best results. Beware anyone who ever tells you that they have found the single greatest answer to everyone’s problems because you can be sure they are wrong.

Back to this example, as I’d told my training partner, “the reverse hyper machine is great”, but is it what he needs?

Are there easier to do options that are BETTER than the reverse hyper? Of course! There are literally dozens of moves that I’d recommend that would be better than the reverse hyper and that do not require this piece of equipment. Not to mention that literally every box gym ever opened has had this piece in it since 1960. Why would it be any more useful now than it ever has been? Silliness.

One other important thing to note is that this machine, and the movement of hip extension by itself (loaded or not), does NOT cause any issue with shearing of a hip replacement or of any part of the hip itself. I say this so that folks with hip pain don’t assume that they cannot perform these movements. They are very safe and useful for safe strengthening of the glutes, hamstrings and the posterior chain. What Danaher could have said is, “because of my specific kind of hip replacement surgery, the surgeon didn’t want me performing any excessive hip extension past neurtal.” Furthermore, if you read the current literature on the precautions that we follow after a hip replacement surgery, the anterior approach is much stronger than we’d known in the past and the hip ligaments are highly unlikely to be disturbed with this motion. John Danaher is probably missing out on a lot of the good that can come from some work into hip extension.

I’m sure that when Joe Rogan exclaimed how amazing this piece was it gave my friend a shot in the arm of hope. Otherwise, he wouldn’t have messaged me for validation. If Rogan had said that “this exercise I do has been helpful for the kind of weakness or pain that I had” and that “maybe it would be helpful for you too” then he’d have been more correct but it might not have created any call to action.

Here are other portions of the episode where some clarification might help:

Episode Timer: 1:12:04 (D: Danaher, R: Rogan)

D: “Things didn’t become critical until my early 40’s, when as the result of walking with a limp my left hip started to become bone on bone. So the problems doubled…”

D: Needed to defer treatment/surgery due to fight schedules D: “Delayed the hip operation as long as I could. I was able to work effectively…”, “…the best I could with my hip problems and of course the original leg (knee) problems.” “… at some point it got to a point where literally if I walked down a NYC block I’d have to stop … and wait for my hip to stop hurting. It became impossible to work with. I ended up getting a full hip replacement.

R: “So, that’s when they shear off the top of your hip and they screw a bolt down in there with a new hip. … And how does it feel now?”

D: “Pain free which is a wonderful thing for me. Like any fake hip it’s not going to be as strong as your real hip.”

THIS is where I would have loved to hear more about Danaher’s case and I wished he’d have reiterated this kind of disability. Many of us are so quick to consult a surgeon for pain and then have to weigh treatment options, some surgeons of which are quick to recommend surgery even when for the most part we are ambulatory and can train and live without too much trouble. Danaher here describes some pretty crippling disability before he made the call to have his hip replaced. This is the best possible situation. It sounds backwards, but as for long term results you want to hold off on these surgeries as late as possible. Once you go in, there’s no getting things back to “standard issue” and new pain and restrictions really start adding up.

The other issue that should be clarified is Rogan’s clear misunderstanding of how hip, or any joint, replacements go. “Shearing off the hip” and “screwing a bolt down there”. Surgeon’s work hard to preserve as much native bone possible. The impression that the hip is “ripped apart” or roughly treated is not an accurate visual. Also, the “rod” that he is referring to is placed into the femur in such a way as to provide a solid fixation and is by itself not a sensitive part of the femur. It can be cemented (or glued) or partially screwed into place. The majority of the trauma in this surgery is to surrounding soft tissues and will also subside given time and good mobility work and rehab.

Yes. Orthopedic surgery is far from gentle. If you want to know what an ortho OR sounds like, just go to the closest auto body shop and close your eyes. The sounds, the smells, … they are pretty much indistinguishable. But, to use the language that Joe used to describe how surgery is performed does nothing but add fear and anxiety for someone who might be in that decision making process. This will absolutely increase your pain and for no real reason. It’s called nocebo: the phenomenon of increasing someone’s pain or fear without actually doing anything to them! More about nocebo in an upcoming post.

Look, if you really need a hip replacement, know for sure that techniques for doing so are always improving and each new change is about reducing pain and improving mobility when the patient is back on their feet; in most cases, the very next day. I was glad, but not surprised, that Danaher reports being pain free after his procedure.

Episode Timer: 1:13:38 (D: Danaher, R: Rogan)

D: “The only problem was that shortly after the hip replacement the knee finally collapsed after 30 years of problems. So I’m going to have to get a knee replacement on the same leg.

R: audible gasp, or something

D: “Knee replacement is much more tricky… There’s not as much bone mass to work with. Generally there’s not a lot of longevity with replacements because there’s much more movement in the knee than there is in the hip; There’s less bone to affix to…

D: “I’m 50 years old. Generally you’d want a replacement that would outlive you. I’m probably going to have to get a second knee replacement when I get older to replace this first which is not ideal but I’m probably going to have to do it.”

R: “Who knows what crazy technology they will have down the line.”

D: “I hope they give me a superhero leg”

Want to point out one thing here that wasn’t explained above. It’s the idea that technology will someday be at a level when we can have superhero parts. The human body and all of its tissues are fricking amazing. Our ability to heal, deal with stresses, train… We truly are all superheroes when it comes to healing. We also have the ability to slow or speed our own healing.

That said, given the average lifespan of a human and the average lifespan of a prosthetic hip or knee, there are few situations when a replaced joint will outlive a person. Second joint replacements, called revisions, are very common practice. Materials sciences are always improving. We can add a few years to the life of certain parts of these devices but it’s not likely we will ever have a one and done solution to these kinds of joint replacement issues. If you need a joint replaced and a surgery can give you 10-15 years of pain free movement (the average life span of knee and hip replacement parts up til now) then you will take it. The need for another surgery down the line will cost you another 2-3 monnths of recovery and then give you another 10-15 years. This is simple math that almost anyone in pain would gamble on. This is also the main reason that “holding off as long as you can” is very important. Careful thought to lifestyle changes that can improve tissue healing or resilience should be taken into consideration as well.

Episode Timer: 1:16:43 (D: Danaher, R: Rogan)

D: “After the hip replacement I could only (teach) verbally. I would point with a stick and they would do the moves for me. There are days when I can barely walk. On those days… I’ll have the students demonstrate for me when needed. I do what I can on the days that I teach.”

R: “It is quite fascinating that a guy who has catastrophic injuries of his leg is one who is known for being an innovator in crushing people’s legs. You were joking around about that being a kind of revenge.”

In this last exchange of the bad armchair doctor section, this is such a cool example of how people can continue to thrive and coach given significant pain and a neat surgical history. You do what you must to continue. You don’t make excuses. If you need make adjustments then you make them. You DON’T curl up into a ball and quit. I just wanted to be sure to point this out for those who might think that their life has to change significantly after a joint replacement. It doesn’t.

Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master’s Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of ‘all the way well’ in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is.

Carlos remains active in several sports and is an avid agility training, power lifting and adventure race runner. He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com.